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Policing Ourselves

By Dr. Raag Airan
. 1 Comment(s)

With all the debate about cost control, it’s clear that we doctors will have to police ourselves – or else politicians and insurance companies will exert even more influence over our practices than they already do. The main question is:

 Are we willing to let our physician colleagues exert influence on our care decisions?

Taking a case from my field: at a conference this past week I met a radiology resident from the U.K. and compared notes about the differences in our practices. The main point we discussed was that, in the U.K., one of the radiologist’s primary roles is to determine which scans are completed. Partly because of the lower density of scanners in the U.K. (e.g. we have double the number of CT scanners per capita in the U.S.), imaging resources are scarcer across the pond than they are here. In that environment, the U.K. radiologist has evolved to be as much a gatekeeper for access to imaging resources, as an interpreter of the scan results. This of course leads to friction between departments, as clinicians ordering the scans are exasperated by radiologists who block the scans for seemingly inappropriate reasons.

We Americans, in contrast, have problems at the other extreme with scans being ordered with seemingly minimal indication. In contrast to my new friend’s training, I will have little to no responsibility for triaging imaging resources at my training sites. The most I will do is advise on which particular scan to order when an ordering provider happens to call, or when the technician doesn’t know how to cohere the scan ordered with the given clinical indication. In most cases, I will only know an inappropriate scan has been completed when the resultant images show up in my list to be read. Despite being a radiology resident for only a few months, I have already seen several scans that I could only describe as inappropriate – for instance, a Chest PA and Lateral completed within 20 minutes after the patient had received a high resolution Chest CT, with no intervening change in the patient’s clinical status. Perhaps my clinical colleagues had a valid reason for such a duplicative study beyond the given clinical history (“cough”), but my cynical side assumes the worst. Our easy access to imaging has led to an over-reliance on imaging in diagnosis, and overutilization of imaging in medicine

So, if you are a radiologist, would you accept an increased responsibility to triage and dole out imaging resources?

If you are not a radiologist, would you accept a shift in control of ordering of imaging services to the radiologist?

Either way, do you think such a shift would be good for patient care?

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  1. Joel Weddington MD

    Raag, very nice post. As an orthopedist, I have ordered thousands of imaging tests over the years, and the pressure to get these tests is incredible. Many patients come with the sole purpose of being refered for an MRI, and others manifest chronic symptoms that eventually get MRI'd to rule out scary pathology (eg tumors/infections). still others have positive findings that don't correlate with symptoms. Sometimes even payers want the studies, so they can get the case done and over with. I think a check and balances could work, but to have a radiologist act as a utilzation and review person could be awkward in the U.S. Personally, I'm comfortable putting two brains together, and working with a rdiologist, but orthos like to cut would be quite offended to have someone question their judgment. The other side is the cost. In Japan, MRIs studies are fixed at $300, and the patient pays 10% of it, helping control waste. We need to control both the volume and the cost to contribute to affordable healthcare in the U.S.

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